‘I think I understand you, doctor’

Chris Hogan

10/12/2021 3:01:01 PM

Associate Professor Chris Hogan explores the importance of health literacy and ensuring patients understand what is being discussed with them.

Female GP talking to patient
Education for both patient and GP is a process of mutual questions and answers, writes Associate Professor Chris Hogan.

The following advice applies to patients who speak your language fluently. Dealing with patients who speak a different language is more complicated still.
Ask first before you tell
The word ‘doctor’ means ‘teacher’, but how many doctors act like a teacher?

How does a teacher know their pupils have learned? They ask them. That is what exams are for − to test not only the pupil but the teacher.

Too many doctors seek to dump data onto people under the assumption that their patient knows nothing about the topic but knows enough to understand a long explanation without discussion.

‘Noddies’ − the nodding of the head while repeating ‘Yes, doctor’ − do not count.

People know a lot about many things. Sadly, a lot of what they know is outdated, incomplete, garbled or just plain wrong.

When we seek to inform, we must first ask them what they know – or think they know.
Education is more than providing a handout, even if that handout is written in the person’s preferred language, in clear and uncomplicated words and sentences with a minimum of jargon.
Education is a process of incorporating new information into what a patient already knows or thinks they know. It is a process of mutual questions and answers.

Using a handout
We do give patients the appropriate handout, with or without pictures or web addresses, but only after the discussion.
The handout is for at least two people: the patient and their informal carer.
Handouts help a patient remember what was said. Without help, patients remember only a fraction of what is said in consultations.

Patients are often overwhelmed during a consultation, which may be for a number of reasons:

  • They are sick, tired, injured, traumatised or sedated (sometimes intoxicated)
  • They were not expecting the diagnosis they were given
  • Their diagnosis is something they know little about
  • They may have poor health literacy or poor literacy
  • There are several words and terms that, when used, will guarantee the patient hears nothing for the next 40 minutes, such as cancer, stroke, heart attack, surgery, STI or pregnancy (especially for a male patient)
My wife helped enlighten me on this topic.
I once spent 40 minutes explaining their newly diagnosed asthma to a patient with the aids of model airways and a handout.

They took their script next door to the pharmacist on duty − my wife.
When the patient was asked what I had said, my wife was greeted only with a blank stare. When prompted, the patient then produced my handout and my wife repeated the explanation, asking questions for clarification.
Informal carers
The informal carer is, unfortunately, often absent from a consultation, but is of extreme importance.
The informal carer is the person the patient goes to for first aid assistance and advice about a cut, a rash, a bite, an injury, a pain or any bodily disturbance. They are usually female and are Mum or ‘the missus’, a partner, or in many cultures, the grandmother. 
They provide assistance and encouragement to see the doctor and to follow the doctor’s instructions – if they trust the doctor. This is not usually a problem as they often recommend the patient attend that particular practitioner.
The carer can be your best friend or your worst enemy.

Health literacy
Health literacy is ‘the knowledge and skills required to understand and use information relating to health issues such as; drugs and alcohol, disease prevention and treatment, safety and accident prevention, first aid, emergencies, and staying healthy’.

In the most recent health literacy survey from 2018, 91% of Australians believed they had at least ‘adequate’ levels of health literacy.
The last assessment in 2006 of the actual, rather than perceived, level of health literacy revealed that only 41% of Australians aged 15–74 were assessed as having ‘adequate’ or ‘more than adequate’ health literacy skills.
This means 59% were not health literate.
Now as for actual English literacy in Australia, literacy skills are becoming increasingly important in our contemporary society.
In 2006, just over half of Australians aged 15−74 years had adequate or better prose (54%) and document (53%) literacy skills.
Although these rates are slightly higher than those a decade earlier in 1996, they still represent a high proportion of people who may be at a disadvantage in finding employment, completing documents and performing other tasks.
Evidence exists of a relationship between literacy skills and a range of factors, including educational level, language, health, age, participation in formal or informal learning, income and labour force participation.  

If experience is what you get when you survive your mistakes, then I must be experienced.

I have learnt that assumptions about what the patient knows or does not know are dangerous and the only way we can help our patients is if we ask a lot more questions before we give explanations.
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